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INSTRUCT IONS
<br /> Et1ud.C,..�';Y Leak Beit ' Confirmed -- Leek suspected at site, &A has not been confirmed,
<br /> indicate whether emergency response personnel and equipment were invoived Pro lirrss`nary Srt.e Assess meat, Worknlran Submitted arkplaallproposal
<br /> at any tire. If so, as .1 az..,dous Material Inc dnn+ Report should be filed requested of/submitted �Y termor ble Party to d terra ne h `her„ round
<br /> with the Stage Of o Emorgenc Se vices (GES) at SSCIQ Meadowview pose, orate le been, or argil be, impacted as a result of the release.
<br /> �,,fz_e a �� y � 7
<br /> S acr,_mentc. CA 95532. Copies of the OE _fi,po,t,, form nzay be obtained at Pr- gjinar Site Assessment inde`wa, - .p ementation of workplan,
<br /> local rderFroar_c s a e to=, is a.. i<t rat e.c,v indicate w_._t_. - pol aa.,iora C <aracter, natio:: - resp risible party is i he process of fully
<br /> the r ES report haz been filed as csf the date A tams r„eportt, defa.n'-fig the extent of contamination won in soil and ground water arca' assessing
<br /> impacts on sanzface and/or ground water,
<br /> LOCAL 10TE On � _.; _ esiediation flan - remediation plan submitted evaluating laza; term
<br /> Toavoidduplicate notification nu;rsua:d:,)�o "e filth and Safe code ectian eamea ation options. Proposal and Lnple.nentation schedule for ap roprzata-,
<br /> 25180.5, a g..ve-;:rnlient employee should sign and date ttaef form in this l k, romeAiation options also submitted,
<br /> signature zsere.'does not mean that the era has been determinepose a
<br /> Le !Lay e e i o? plan,
<br /> lenu � Proei >`sprclu
<br /> significantthreat, to ii-unan health n safety, only that not ficati rad-, C � _round water or other
<br /> pro e_ have bene fo_o ed if xecuived _, nxeni' o ing; at site as npac swrv, to verify and/or evaluate c_fe iveness
<br /> _.,
<br /> of r.r di<al activr :es, %
<br /> lxrrC??,ml:D EY ,;; _ Casa C,..c,soa�� - z egicanal. towti t+n;"t 1oc,a2 agr;ay in c:,z-ac..r ser*ce that no
<br /> Enter your name, tenphanc u'ln>ar, and a dz, _.. , indicate Which party Y--j furthex work is necessary a; the site.
<br /> present and providiaj-_,ono eery narne
<br /> arfa'a3RTANr THE., INFORMATION PROVIDED DED ON THIS �'w
<br /> ORO IS INTENDED FOR Esi'NERAL
<br /> ESsdtn LE R2”i' STAT STtCA3L PURPOSES GSiIY AMD S C,
<br /> NOT TO BE CONSTRUED AS ,,tiEPRI.SENTIN ^;
<br /> T
<br /> ._ f �C AA POSITION OF ANY (V)VTZRNm�NTA1, _,,,,AUC
<br /> Enter ..as:e, .e.te>r_.G,n„~ ra�....,-r, contact i.axm n, vlcare"s of the n a°w°t
<br /> e Baca- h1a for the as, Me reepmsAle, a_,rtzl wo _.d. r:arm6 a Y nk .he tank
<br /> or._,,r. ih a 2I. 2ffi
<br /> indivan't araAN, acorn have been used t, ,. .u.. p ar etdiate the leat,
<br /> SIT. a A.F�ON e.„crzpt ops of pt.�wls fo'f.low:
<br /> __. _..
<br /> Znte information reSarding the tank iacz1,,ity-, At a r1inine,211, you must
<br /> provide the facility namb.and aft 1 address. Sao Site - install horizontal impermeabLe laver to educe rainfall
<br /> ... _ ..,
<br /> infiltration,
<br /> ItILE _,.vl!N
<br /> _ Co-, I a sinstall vertical dike to b1o;k 1eri ontalmovementof
<br /> Enter namesof to ctal agency and -
<br /> egEonr- y�,ter, Quality CotAtrsal Board contaminant.
<br /> involved, Excavate An.�--Dis Safe .., remo-ve cont.<inin:ated soil and dispose in Va proved
<br /> r
<br /> site,
<br /> SUBS-1 .'de..” T.,d "a:'E.ai a r area, r_c,o ion <.-.na.-W so,,! and ureas, Cinclludez spreadingExt lv a�
<br /> Enter ,he no and quantity i." t, of t° u a u a Sub nce,i sofv 'arras-: �. land� n V
<br /> is provided for iaforatation on two sub -ancer .if approprsate, if come own Emma Fog P=Qt remove fl prod-act ffom water table,,
<br /> tva Sus an as` leaked, list the two of most, concern fpr !-a up, � Ire,� Grorzr a - Sia era�y e F, Loye,,i � _. a o; �o - d
<br /> b
<br /> cont-ssin ants.
<br /> aacd-.asada'tLaL, use of any avolable tecllnolny to promote
<br /> y
<br /> Provide _ regardingtle discovery a r statement of warIsak, bacterial
<br /> ac e aai s
<br /> om a f
<br /> Su_ t� p..krre aIcuarnu
<br /> at_.e water -ala �k vv . ct*s parties.
<br /> C ,-fCtCaS? x d a hookainstall,wu ria s u o_.Lwe. a each lraad lin or
<br /> I dicate of .',-ask, Check tvcr. es) i.dic<.:ing carie of leaks e co`oE a
<br /> �fi lar r use, r"ImpX c i h a through e.
<br /> of
<br /> � '; ! immudia3Indicate Luc ewe ,ie tegca Ar rds le Check one box only. asp ascr r
<br /> type is based on the most e zr :_ rc r oto ed For exampLe. i
<br /> both a-: and gx � water 'have been affect.o, ca-s type gala b .ou. � �_ 1,t... this e ,.vutz?_c €_A aspects of the incident,
<br /> Water-. sar r a oW, if nw or moze n..n c.r.ai or
<br /> dair:,n„wic r, s.G,r w_l.o have allwdQ ,zc,.,a i..ae€.au, A "Ground Water" `mdaM"RE +Sf�n t,2,:a
<br /> mm in the space cava
<br /> desanation does not .'ta that e. �xt . c , ot'bj or is no-
<br /> used
<br /> , ,us t f r vwba only that w,'m,,er wellshave not ret bo
<br /> a
<br /> affected. is .oder_t d that ewe type may c,laaz ye upazfurther if we l m i on .e c a by Una twk omer or hisa t" s t y
<br /> re"
<br /> in
<br /> q w tion' so x forward as s_cmys ing cup"s cup", iQ=t to y _r i as t:. r.—PA A9 ata m'
<br /> s
<br /> ,.a.<< A,,:.,.,cs`
<br /> indicaLe
<br /> ., caoegcry 4w,....h best descr&e4 thez.r .nt ; ..a.us of aan. 1r 2. State NaLer C-. cu .0 1 .. u-, "",J,aanF 'C
<br /> _ .- "t F _�.t ,7,3:.iT.d T.;G^rn .C6x l ., .,. v,S IS, �.w ..,C E (.A
<br /> e x a;-..y, oda ear mw d"be a:� we to tie ease . v 9044-
<br /> Check
<br /> W14 refer
<br /> to < g r as v a s x a,cs le. �. i
<br /> s oza s
<br /> that ,ter �� �. � _ an ow rd .a n ,. i
<br /> a. ti���#-t_.._a,_ .r tt >,t � � Lwal E r a > z�:�, a. �a�
<br /> Ke
<br /> T � <
<br /> N.. :,_ a Tien No act:c._V.s k... by >rsd,a..sitle pasta , heywA 5. a;ha �1_ .<a _..,�'�w.
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